Written by: Stephen Stockhausen PT, DPT, OCS
I have to warn you in advance. This article is going to be part advice and part tirade against the complacency and general obliviousness that unfortunately has seeped into physical therapy, and even the travel PT community. Sure, I could list a dozen valid and useful tips to improving your clinical skills both as a perm PT or travel physical therapist, but then again, you likely already know all of that stuff. Truly, when it all gets boiled down to the keystone principle, there is only one secret to becoming an expert PT.
The art and science of physical therapy is undoubtably a cognitively demanding one. Our simple minds have to evaluate and assess multitudes of data points flooding our system all at once to suss out an accurate diagnosis and formulate the appropriate treatment plan. Juggling patient medical history, medication usage, socioeconomic status, psychosocial factors, belief systems about pain, healing, or medical utilization, subjective report of the injurious incident, locality and radiation of symptoms, clusters of symptoms, symptom changes due to position, movement, time of day, stress, medications, or application of heat or cold. We consider tissue response to palpation, stretch, contraction, compression, and special tests. We check joints up stream and down stream, we check myotomes and dermatomes and DTRs, and we check breathing patterns. We evaluate for malingering (though we don’t like to admit it), fear avoidance, and most importantly, red flags. And this is just for one patient. Not to mention the list of more to come later in the day or who may already be at the clinic! (Oh, and then you have to document it all…) All of this seems so overwhelming at times, but for the truly great clinicians it is effortless.
Ultimately what separates these great clinicians from the rest of us is their ability to recognize patterns in patient presentations. While even the greenest of new grads can effectively utilize a clinical prediction rule (for better or worse), an advanced clinician essentially has hundreds of the same patterns engrained into their own treatment algorithm. How do they do this? Simple. They Pay Attention!
As the esteemed psychologist Anders Ericsson was so famously misquoted, it takes 10,000hrs of deliberate practice to become Elite in nearly any field. (It turns out that depending on your own proclivities it is actually anywhere from 4,000 – 24,000 hrs, but hey, 10,000 is a nice round number). More importantly than the specific number, is the qualifier attached to those hours – Deliberate Practice. Deliberate practice is intention filled focused time analyzing, evaluating, reevaluating, and adapting. It is the skill drills LeBron James and Steph Curry do ad nauseam when the cameras are off and everyone has left the gym. It is the brutal work hours with real patients that surgical residents must survive before striking out on their own.
So what does this look like in physical therapy? Pay Attention. It is making the test-re-test method like breathing. It is honing the less demanding clinical skills until they are nearly running on auto-pilot (this is why old school CI’s make students complete full neuro screens in under 3 min) It is never taking anything for granted. If something doesn’t fit your expected pattern take note. Maybe it is something. Maybe it is nothing. Most likely it is nothing… but it could be something. And possibly something very important or scary. Deliberate Practice in physical therapy means that we do not jump to conclusions. ALL data points are important until proven otherwise. True, zebra diagnoses exist, but they are still possibilities that need to be on your hypothesis list.
Pay Attention. Words matter more than we often acknowledge. “Not really,” and “No” are very different answers when asked if a client looses bowel or bladder control. Just as, “I have pain at night” is very different from, “when I sleep with my arm over my head it hurts to roll on that side while in bed.”
Paying better attention starts by going one level deeper. It is too overwhelming to drill down to the core on every aspect of every patient on day one. Start simple. During the subjective portion of the visit ask 2-3 extra clarifying questions that you might not normally ask. “So you said your knee was aching after walking up a few stairs, can you show me with one finger exactly where it was hurting? Did that pain linger or was it gone quickly? Is it better when you take your weight off of it? etc..” I know this all sounds so simple but after my recent experience doing internal chart audits, these things get missed ALL THE TIME! What if the pain was on the outside of the knee? What if it actually didn’t stay in the knee but traveled up the lateral thigh some? Oh, and occasionally their low back was sore, but not really bad. How much VMO strengthening and how many patellar glides will it take to get them better? Hopefully all of this is obvious to you, but if not, our poor hypothetical patient will never feel better, but at least they will have killer quads.
The beauty of forcing yourself to go one step deeper than you normally would is that it has a compounding effect. As you are more accustomed to asking penetrating questions it becomes second nature. Now, to get a little deeper you have to expand your search. Maybe you decide to palpate more thoroughly or in a different matter. Maybe you utilize a top down movement screen that you have never implemented before. Maybe, one day you will do both. Incrementally, all of the crazy data points that initially boggled your mind will seamlessly fall into place, creating a more clear picture of your patient and how to best serve them.
Sure, you can sign up for an expensive residency or take a dozen CEU courses that will provide you with a more systematic framework through which to approach your patient’s care, but even with that proprietary scaffold in place it does not guarantee successful results. It is only YOU that can provide the intent and focus and critical thinking skills to truly achieve a great outcome with your client. It is up to you to take control of your career, and it starts one level at a time.
Pay Attention!
